Comparison of knowledge, attitudes and hand hygiene behavioral intention in medical and nursing students.


Hand hygiene
healthcare occupations students


Introduction: Hand hygiene is crucial to prevent cross infection. Healthcare students are in a prime position to learn hand hygiene skills. The aim of this study was to analyze hand hygiene behavioral intentions of healthcare students before and after contact with the patient and to compare the knowledge of and attitude towards hand hygiene between medical and nursing students. Methods: In a descriptive survey research design, convenience selection of a sample of medical students (n=657) and nursing students (n=303) was done from modules taught by the Department of Preventive Medicine and Public Health in both Medicine and Nursing undergraduate degrees in four Spanish universities. The hand hygiene Questionnaire, a validated instrument to evaluate behavior, knowledge, and attitudes, was used. Results: A significantly lower percentage of students reported always or almost always carrying out hand hygiene before contact with the patient or invasive procedures in comparison to the percentage complying after contact with secretions or with the patient. Although hand hygiene knowledge appears acceptable, its importance is not sufficiently valued.Conclusions: There are deficiencies in behavioral intention, knowledge, and attitudes related to hand hygiene in medical and nursing students. Better results are observed among nursing students, especially those who have received specific training.


Haas JP, Larson EL. Measurement of compliance with hand hygiene. J Hosp Infect 2007; 66: 6-14.

Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009; 73: 305-315.

Pittet D, Mourouga P, Perneger TV and the Members of the Infection Control Program. Compliance with handwashing in a teaching hospital. Infection control program. Ann Intern Med 1999; 130: 126-130.

Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Burillo J, Requena-Puche J, Terol-García E, Kelley E, Gea-Velazquez de Castro MT, the ENEAS work group. Impact and preventability of adverse events in Spanish public hospitals: results of the Spanish National Study of Adverse Events (ENEAS). Int J Qual Health Care 2009; 21(6): 408-414.

Klevens RM, Edwards JR, Richards CL, Horan TC, Gaynes RP, Pollock DAP, Cardo DM. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007; 122: 160-166.

Pittet D, Donaldson L. Clean care is safer care: The first global challenge of the WHO world alliance for patient safety. Am J Infect Control 2005; 33: 476-479.

Pittet D, Allegranzi B, Boyce J, World Health Organization World Alliance for Patient Safety First Global Patient Safety Challenge Core Group of Experts. The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. Infect Control Hosp Epidemiol 2009; 30(7): 611-622.

Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. Handwashing compliance by health care workers: The impact of introducing an accessible, alcohol-based hand antiseptic. Ann Intern Med 2003; 160: 1017-1021.

Hilburn J, Hammond BS, Fendler EJ, Groziak PA. Use of alcohol hand sanitizer as an infection control strategy in an acute care facility. Am J Infect Control 2003; 31: 109-116.

Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000; 21: 381-386.

Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL, Donaldson L, Boyce JM, WHO Global Patient Safety Challenge, World Alliance for Patient Safety. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006; 6(10): 641-652.

Trick WE, Vernon MO, Welbel SF, Demarais P, Hayden MK, Weinstein RA, Chicago Antimicrobial Resistance Project. Multicenter intervention program to increase adherence to hand hygiene recommendations and glove use and to reduce the incidence of antimicrobial resistance. Infect Control Hosp Epidemiol 2007; 28(1): 42-49.

Erasmus V, Daha, TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, van Beeck EF. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010; 31(3): 283–294.

Haas JP, Larson EL. Compliance with hand hygiene guidelines. Am J Nurs 2008; 108 (8): 40-44.

Helder OK, Latour JM. Undergraduate nurse students' education in infection prevention: is it effective to change the attitude and compliance with hand hygiene? Nurs Crit Care 2010; 15 (1): 39-40.

Fuller C, Michie S, Savage J, McAteer J, Besser S, Charlett A, Hayward A, Cookson BD, Cooper BS, Duckworth G, Jeanes A, Roberts J, Teare L, Stone S. The Feedback Intervention Trial (FIT)--improving hand-hygiene compliance in UK healthcare workers: a stepped wedge cluster randomised controlled trial. PLoS One 2012; 7(10): e41617.

Lee A, Chalfine A, Daikos GL, Garilli S, Jovanovic B, Lemmen S, Martínez JA, Masuet Aumatell C, McEwen J, Pittet D, Rubinovitch B, Sax H, Harbarth S; MOSAR-04 Study Team. Hand hygiene practices and adherence determinants in surgical wards across Europe and Israel: A multicenter observational study. Am J Infect Control 2011; 39(6): 517-520.

Novoa AM, Pi-Sunyer T, Sala M, Molins E, Castells X. Evaluation of hand hygiene adherence in a tertiary hospital. Am J Infect Control 2007; 35(10): 676-683.

Scheithauer S, Lemmen SW. How can compliance with hand hygiene be improved in specialized areas of a university hospital? J Hosp Infect 2013; 83(1): 17-22.

Morris ZS, Clarkson PJ. Does social marketing provide a framework for changing healthcare practice? Health Policy 2009; 91(2): 135-141.

Gould DJ, Moralejo D, Drey N, Chudleigh JH. Interventions to improve hand hygiene compliance in patient care. Cochrane database of systematic reviews 2010; 8 (9): CD005186.

Fisher D, Pereira L, Ng TM, Patlovich K, Teo F, Hsu LY. Teaching hand hygiene to medical students using a hands-on approach. J Hosp Infect 2010; 76(1): 86-87.

D'Alessandro D, Agodi A, Auxilia F, Brusaferro S, Calligaris L, Ferrante M, Montagna MT, Mura I, Napoli C, Pasquarella C, Righi E, Rossini A, Semeraro V, Tardivo S; GISIO. Prevention of healthcare associated infections: medical and nursing students' knowledge in Italy. Nurse Education Today 2014: 34(2): 191-195.

Graf K, Chaberny IF, Vonberg RP. Beliefs about hand hygiene: a survey in medical students in their first clinical year. Am J Infect Control 2011; 39 (10): 885-888.

Mann CM, Wood A. How much do medical students know about infection control? J Hosp Infect 2006; 64(4): 366-370.

Tavolacci MP, Ladner J, Bailly L, Merle V, Pitrou I, Czernichow P. Prevention of nosocomial infection and standard precautions: knowledge and source of information among healthcare students. Infect Control Hosp Epidemiol 2008; 29(7): 642-647.

Gantt LT, Webb-Corbett R. Using simulation to teach patient safety behaviors in undergraduate nursing education. J Nurs Educ 2010; 49(1): 48-51.

Hautemanière A, Diguio N, Daval MC, Hunter PR, Hartemann P. Short-term assessment of training of medical students in the use of alcohol-based hand rub using fluorescent-labeled hand rub and skin hydration measurements. Am J Infect Control 2009; 37 (4): 338-340.

Snow M, White G, Alder SC, Stanford JB. Mentor's hand hygiene practices influence student's hand hygiene rates. Am J Infect Control 2006; 34: 18-24.

González-Cabrera J, Fernández-Prada M, Martínez-Bellón MD, Fernández-Crehuet M, Guillén-Solvas J, Aurora Bueno-Cavanillas. Construcción y validación de un cuestionario para medir conductas, conocimientos y actitudes sobre la higiene de las manos en personal sanitario. Rev Esp Salud Publica 2010; 84: 1-15.

Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. “My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007; 67: 9-21.

Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force Am J Infect Control 2002; 30: 1-46.

Grayson ML, Russo PL, Cruickshank M, Bear JL, Gee CA, Hughes CF, Johnson PDR, McCann R, McMillan AJ, Mitchell BG, Selvey CE, Smith RE, Wilkinson IJ. Outcomes from the first 2 years of the australian national hand hygiene initiative. Med J Aust 2011; 195 (10): 615-619.

Schweizer ML, Reisinger HS, Ohl M, Formanek MB, Blevins A, Ward MA, Perencevich EN. Searching for an optimal hand hygiene bundle: a meta-analysis. Clin Infect Dis 2014; 58(2): 248-259.

Lau T, Tang G, Mak K, Leung G. Moment-specific compliance with hand hygiene. Clin Teach 2014; 11(3): 159-164.

Whitby M, McLaws M, Ross MW. Why healthcare workers don't wash their hands: a behavioral explanation. Infect Control Hosp Epidemiol 2006; 27: 484-492.

Al Kadi A, Salati SA. Hand Hygiene Practices among Medical Students. Interdiscip Perspect Infect Dis 2012; 679129.

Hall L, Keane L, Mayoh S, Olesen D. Changing learning to improve practice - hand hygiene education in Queensland medical schools. Healthc Infect 2010; 15 (4): 126-129.

Nasirudeen AMA, Koh JWN, Lau AL, Li W, Lim LS, Ow CY. Hand hygiene knowledge and practices of nursing students in Singapore. Am J Infect Control 2012; 40(8): 241-243.

Scheithauer S, Haefner H, Schwanz T, Lopez-Gonzalez L, Bank C, Schulze-Röbbecke R, Weishoff-Houben M, Lemmen SW. Hand hygiene in medical students: performance, education and knowledge. Int J Hyg Environ Health 2012; 215(5): 536-539.

Tella S, Liukka M, Jamookeeah D, Smith NJ, Partanen P, Turunen H. What do nursing students learn about patient safety? An integrative literature review. J Nurs Educ 2014; 53(1): 7-21.

van De Mortel TF, Apostolopoulou E, Petrikkos G. A comparison of the hand hygiene knowledge, beliefs, and practices of Greek nursing and medical students. Am J Infect Control 2010; 38(1): 75-77.

van De Mortel TF, Kermode S, Progano T, Sansoni J. A comparison of the hand hygiene knowledge, beliefs and practices of Italian nursing and medical students. J Adv Nurs 2012; 68(3): 569-579.

World Health Organization. WHO patient safety curriculum guide for medical schools 2013 [accessed on 2013 April 20]. Available at:

Duggan JM, Hensley S, Duggan JM, Hensley S, Khuder S, Papadimos TJ, Jacobs L. Inverse correlation between level of professional education and rate of handwashing compliance in a teaching hospital. Infect Control Hosp Epidemiol 2008; 29(6): 534-538.

Aziz AM. How better availability of materials improved hand-hygiene compliance. Br J Nurs 2013; 22(8): 458-463.

Reichardt C, Königer D, Bunte-Schönberger K, van der Linden P, Mönch N, Schwab F, Behke M, Gastmeier P. Three years of national hand hygiene campaign in Germany: what are the key conclusions for clinical practice? J Hosp Infect 2013; 83(1): 11-16.